Risk Factors for Unexpected Admission Following Lumbar Spine Laminectomy: A National Database Study.

Introduction Laminectomy is one of the most common orthopedic spine surgeries performed in the United States. Compared to other spine operations such as fusions, laminectomies in isolation are of lower morbidity. However, complications may arise that result in readmission to an inpatient healthcare facility. The purpose of this study is to identify the demographics and risk factors associated with unplanned 30-day readmission following a laminectomy. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients who underwent a laminectomy procedure from 2015 to 2019 using CPT code 63030. This query yielded 61,708 cases. Demographic, lifestyle, comorbidity, and peri-operative factors were recorded. Independent samples Student's t-tests, chi-squared, and, where appropriate, Fisher's exact tests were used in univariate analyses to identify demographic, lifestyle, and peri-operative variables related to 30-day readmission following a laminectomy procedure. Multivariate logistic regression modeling was subsequently performed. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated and reported. Results Of the 61,708 patients included in our sample, 2,359 were readmitted within 30 days of surgery, corresponding to a readmission rate of 3.82%. Results of the univariate analysis revealed statistically significant relationships between readmission status and the following patient variables: patient age, sex, BMI, ASA classification, race, bleeding disorder, chronic obstructive pulmonary disease (COPD), diabetes, hypertension, congestive heart failure (CHF), chronic steroid use, total operative time, and tobacco use (p < 0.05). Multivariate logistic regression modeling confirmed that the following patient variables were associated with statistically significantly increased odds of readmission: age greater than 65 (p < 0.05), female sex (p = 0.013), bleeding disorder (p = 0.011), diabetes (p = 0.006), current smoker (p = 0.010), COPD (p < 0.001), steroid use (p = 0.006), ASA Class II or above (p < 0.05), and total operative time (p < 0.001). Conclusion Unplanned 30-day readmission after laminectomy is infrequent. However, increasing age, female sex, steroid use, current smokers, bleeding disorders, diabetes, COPD, CHF, a higher ASA classification, and longer operative times are independent risk factors for readmission following laminectomy.

The Relationship Between Patient Demographics, Tear Locations, and Operative Techniques on the Surgical Treatment of Acute Achilles Tendon Ruptures.

Introduction Achilles tendon ruptures (ATRs) have classically been thought to affect the middle-aged "weekend warrior" participating in basketball, volleyball, soccer, or any ground sport; however, with a more active elderly population, these tears are becoming more common in older patients. We sought to examine the role of demographics, tear location, and operative technique for acute Achilles tendon ruptures treated surgically. Methods A retrospective query was performed to identify patients who presented with Achilles tendon ruptures. Inclusion data were primary end-to-end repairs, augmented repairs with flexor hallucis longus (FHL) transfers, augmented repairs with graft, augmented repairs with both FHL transfer and graft use, isolated FHL transfers, and revision Achilles tendon procedures. Demographics and tear locations were collected and analyzed. Results Midsubstance tears were the most common tear location occurring in 237 of 286 (82.9%) patients. Distal insertional tears of the Achilles tendon were treated in 35 (12.2%) patients, while 14 (4.9%) patients had a more proximal tear located at the myotendinous junction. Older patients (average age: 53.3±12.5) had significantly more distal insertional tears (p<0.001), while younger patients (average age: 35.1±7.4) presented with significantly more tears at the myotendinous junction (p<0.001). The average BMI was significantly higher (average BMI: 32.2±6.6; p<0.001) in patients with distal insertional tears compared to midsubstance and proximal tears (28.5±4.6 and 28.5±5.3, respectively). There was a higher percentage of diabetic patients who underwent operative treatment for distal insertional tears (20%) compared to midsubstance tears (7.2%). Conclusion The findings of our study suggest that a subset of patients, particularly those with advanced age and higher BMI, is more likely to present with a distal Achilles tendon rupture. Additionally, patients in our series who had distal tears more commonly required an augmented repair technique. Our results highlight the need for future research to further define the relationship between increasing age and higher BMI patients sustaining distal tears more often than midsubstance tears.

Differences in Fourth-Year Orthopaedic Away Rotation Opportunities and Fees Among Osteopathic and Allopathic Medical Students 1 Year After the Implementation of the Single Accreditation System.

Fourth-year away rotations are well recognized as an important modifiable variable that has been shown to increase a student's opportunity to match into orthopaedic surgery. The purpose of this article was to determine whether allopathic (MD) and osteopathic (DO) medical students have equal opportunities for away rotations in terms of (1) eligibility and (2) fees associated with rotations after the single accreditation merger. Methods: A cross-sectional study was performed during the 2021 application cycle (April to November) by reviewing all nonmilitary, Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery programs (n = 194). Each program's website, affiliated school of medicine's website, and visiting student applications service portal were searched. Eligibility criteria for an away rotation and associated fees were recorded. Results: Of the 194 programs, 18 (9.3%) of programs were found to have publicly published eligibility for away rotations that prohibited students based on applicant degree. Five (2.6%) programs/medical schools had fees that were larger for DO medical students compared with MD medical students ranging for $50 to $5,000. No programs/medical schools had larger fees for MD medical students compared with DO medical students. Conclusions: Although DO and MD degrees are equivalent degrees for licensing and credentialing and graduate medical education has transitioned to a single accrediting body, there remained discord in the opportunities for fourth-year away rotations between osteopathic and allopathic medical students. This study highlights the necessity for greater reform, consistency, and transparency among orthopaedic surgery residency programs and their affiliated institutions.

The Association of Immediate-Use Steam Sterilization with the Incidence of Orthopaedic Surgical Site Infections: A Propensity Score-Matched Cohort Study.

BACKGROUND: Immediate-use steam sterilization (IUSS), formerly termed "flash" sterilization, has been historically used to sterilize surgical instruments in emergency situations. Strict guidelines deter its use, as IUSS has been theorized to increase the risk of surgical site infections (SSIs), leading to increased health-care costs and poor patient outcomes. We sought to examine the association between the use of IUSS and the rate of orthopaedic SSIs. METHODS: The cases of 70,600 patients who underwent orthopaedic surgery-total knee or hip arthroplasty, laminectomy, or spinal fusion-from January 2014 to December 2020, were retrospectively reviewed for IUSS use. Of this group, 3,526 patients had had IUSS used during surgery. A propensity score-matched (PSM) analysis was conducted to account for known predictors of SSIs and included a total of 7,052 patients. The risk difference (RD), relative risk (RR), odds ratio (OR), and McNemar test compared the SSI risk for patients whose procedure had included the use of IUSS and those whose procedure had not included IUSS. RESULTS: After propensity score matching, 111 (1.57%) of the 7,052 matched patients developed an SSI. Of the 111 patients, 61 (54.95%) were in the IUSS group and 50 (45.05%) were in the non-IUSS group. The estimated probability for developing an SSI was 1.42% for the patients in the non-IUSS group versus 1.73% for the patients in the IUSS group (RR = 0.82 [95% confidence interval (CI)]: 0.57 to 1.19], RD = -0.3% [95% CI: -0.9% to 0.27%]).There was no evidence that the proportion of SSI was greater in the IUSS group (McNemar test, p > 0.29). CONCLUSIONS: SSI rates were not significantly different between IUSS and non-IUSS patients undergoing orthopaedic surgery. Future prospective studies are warranted to further explore the utility of IUSS during orthopaedic procedures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Epidemiology and Clinical Outcomes of Foot and Ankle Trauma During the First Wave of the COVID-19 Pandemic in the New York Metropolitan Area.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel respiratory virus that has rapidly changed the practice of medicine. The authors sought to evaluate the clinical presentation and clinical outcomes of patients presenting with foot and ankle (F&A) trauma to the emergency department during the first wave of the pandemic. The authors retrospectively studied all patients who presented to an emergency department within their multicenter institution during the first wave of the pandemic in their region from March 1 to June 30, 2020, with F&A trauma. They compared this cohort with a matched control group of patients who presented the prior year. Demographics, perioperative factors, coronavirus disease 2019 (COVID-19) polymerase chain reaction testing/positivity rates, 30-day readmissions, and 30-day mortalities were collected and analyzed. During the pandemic, the authors saw a 62.0% decrease in the total number of patients presenting with F&A trauma. Patients who presented during the pandemic were significantly older and a greater proportion were male. There was a greater proportion of ankle fractures, fewer ankle sprains, and more open fractures presenting during the pandemic. A greater proportion of patients presenting to the emergency department were admitted (18.2% vs 12.5%). The 30-day readmission (n=13 [5.8%] vs n=38 [9.3%]) and mortality (n=4 [1.8%] vs n=3 [0.7%]) rates for admitted patients were similar (P=.114 and P=.232, respectively). The authors found that 9.6% of patients who presented had a positive COVID-19 polymerase chain reaction test result and that these patients had 20% mortality and readmission rates. [Orthopedics. 2021;44(5):313-319.].

Delay in Treatment of a Bimalleolar Ankle Fracture during Coronavirus Disease-19 COVID-19 Pandemic Leading to Amputation.

INTRODUCTION: Severe acute respiratory syndrome coronavirus-2 (SARs-CoV-2), also known as coronavirus disease-19 (COVID-19), is a novel respiratory disease which has fundamentally disrupted societal norms. Common responses to the pandemic have called for "social distancing" and national lockdowns. There is little evidence as to how public perception surrounding exposure to the virus may impact patient care. Here, we present a case of a patient who deferred medical treatment due to concerns regarding exposure to the virus. CASE REPORT: A 99-year-old female who presented to an emergency department of a community hospital on Long Island, New York, during the COVID-19 pandemic complaining of right ankle pain after a fall three 3 weeks ago. Fear of contracting COVID-19, led to initial avoidance of medical evaluation. On presentation, the patient presented with a Gustillo-Anderson Grade III A, bimalleolar ankle fracture with associated gangrene. After evaluation and a thorough discussion with the patient and her family, the patient underwent guillotine amputation. CONCLUSION: Public perception surrounding COVID-19 has created a sense of fear that can impact patient behaviors, such as prevent them from seeking medical care when necessary. As physicians, we need to make patients feel safe and increase availability to patient care during this time to prevent similar issues as demonstrated in this case.

The Effect of Operating Room Size on Orthopaedic Surgical Site Infection Rates.

OBJECTIVE: With many preventable causes of surgical site infections (SSIs) identified, the effect of operating room (OR) size on SSI rates has not been assessed. This study investigated the effect of OR size on incidence of SSIs for orthopaedic procedures. BACKGROUND: SSIs remain a common complication within the perioperative realm. Responsible for increasing length of hospitalization and costs, SSIs result in a decreased quality of life for patients. METHODS: A retrospective review of 11,163 patients who underwent orthopaedic surgery-including total knee and hip arthroplasties, laminectomies, and spinal fusions-between January 2018 and January 2020 were reviewed. Total net square footage (NSF) of all ORs was recorded, and incidence of SSIs was calculated. Cases were categorized based on the size of the OR (small: 250 to 399 NSF; medium: 400 to 549 NSF; and large: 550 to 699 NSF). Chi-square analysis compared infection rates between the different OR sizes, and a binary logistic regression model identified other predictors of infection. RESULTS: Overall, 137 patients (1.2%) developed an SSI. Of these infections, 16 (11.7%) occurred in small ORs, 83 (60.6%) in medium ORs, and 38 (27.7%) in large ORs. The incidence of SSIs was 0.7% in small ORs, 1.3% in medium ORs, and 1.8% in large ORs. Factors found to significantly impact SSI's included medium-sized ORs, younger patients, procedure type (fusions and emergencies/traumas), longer procedures, and higher American Society of Anesthesiologists scores (>3). CONCLUSION: Our study shows that OR size in addition to various other perioperative parameters plays a role in the rate of SSIs for orthopaedic procedures. LEVEL OF EVIDENCE: Retrospective Cohort Study; Level III Evidence.

Case Study: Trans-styloid, Trans-scaphoid, Trans-triquetral, and Perilunate Dislocation.

Introduction: Perilunate dislocations are rare high-energy injuries, and the diagnosis is not infrequently missed at initial presentation. The combination of fractures resulting in a trans-styloid, trans-scaphoid, and trans-triquetral perilunate fracture dislocation is extremely rare. Early recognition and diagnosis of these injuries is prudent to restore patient function and prevent morbidity. This injury pattern may progress through several distinct phases often involving the greater or lesser arc. The injury begins with traumatic disruption of the scapholunate joint, followed by an ordered progression of injury to the capitolunate, lunotriquetral, and radiolunate joints. When the radiolunate joint is disrupted, the lunate often dislocates volar transposing into the carpal tunnel, associated with median nerve compression. These injuries have the potential to cause lifelong disability of the wrist. Early treatment may prevent or lessen the chance of median neuropathy, post-traumatic wrist arthrosis, chronic instability, and fracture nonunion. Non-operative treatment is not indicated and is associated with poor functional outcomes and recurrent dislocation. Open reduction and internal fixation (ORIF) with ligamentous repair after emergent closed reduction and splinting is indicated for acute injuries (<8 weeks after injury). Case Report: We report a case of a 48-year-old right hand dominant male with a trans-styloid, trans-scaphoid, trans-triquetral, and perilunate dislocation after mechanical fall from height. He was evaluated in the ER and provisionally treated with closed reduction and splinting. ORIF of scaphoid, radial styloid, and triquetrum was performed, with ligamentous repair of the scapholunate joint and carpal tunnel decompression. Conclusion: The combination of fractures/injuries in this case has been very rarely been published in case reports to date. It is necessary to recognize these wrist injuries. Great detail should be given to physical and radiographic evaluation, as adequate reduction can help prevent median nerve damage and minimize post-injury complications such as cartilage damage, avascular necrosis, chronic pain, and deformity. As most cases present in the acute setting, ORIF and ligamentous repair are most likely to maximize return of function. While operative intervention can help to minimize sequelae, functional outcomes are generally poor following these injuries.

Risk factors for complications and in-hospital mortality: An analysis of 19,834 open pelvic ring fractures.

BACKGROUND: Open pelvic fractures are rare injuries, associated with high patient morbidity and mortality. Few studies have investigated the impact of patient demographics, comorbidities, and injury related factors on complication and mortality rates. The purpose of this study was to: (1) identify the overall incidence of complications and mortality after open pelvic fractures, (2) compare patient factors between those who did and did not develop complications, (3) identify perioperative independent risk factors for complications and mortality. METHODS: A query was performed for patients with open pelvic fractures between 2007 and 2017 using the American College of Surgeons National Trauma Data Bank. Patient and injury specific variables were collected and complications were identified using International Classification of Disease Ninth and Tenth edition Codes. Patient demographic and perioperative data was compared using Fisher's exact test and chi-square test for categorical variables, and Welch's t-test for continuous variables. Using pooled data from multiple imputations, logistic regressions were used to calculate odds ratios and confidence intervals of independent risk factors for complications. RESULTS: A total of 19,834 open pelvic fracture cases were identified, with 9622 patients (48.5%) developing at least one complication. Patients who developed complications were older (35.0 vs 38.1 years), and had higher Injury Severity Scores (17.7 vs 26.5), lower Glasgow Coma Scores (14.2 vs 11.7), and a larger proportion presenting with hypotension (21% vs 6.9%). After pooled regression involving 19 factors, these were the strongest independent predictors of inpatient complication and mortality. CONCLUSION: We report a mortality rate of 14%, with an inclusive complication rate of 48.5%. Evaluating risk factors for morbidity and mortality for this devastating orthopaedic injury provides knowledge of an inherently sparse population. LEVEL OF EVIDENCE: Level II, Retrospective study.

Risk factors for hospital admission in patients undergoing outpatient anterior cruciate ligament reconstruction: A national database study.

INTRODUCTION: Anterior Cruciate Ligament Reconstructions (ACLR) are routinely performed in an outpatient setting with low 90-day readmission rates (2.3%); however, admissions rates in the immediate perioperative period have been previously reported as high as 13.1%. Despite the surprisingly high number of patients requiring immediate perioperative admission, there has been a lack of recent literature specifically examining the associated risk factors for admission. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, a query for patients who underwent ACLR from 2011 through 2018 was performed using Current Procedural Terminology codes. The following concomitant procedures were included: meniscectomy, meniscal repair, diagnostic arthroscopy, loose body removal, synovectomy, chondroplasty, abrasion chondroplasty, drilling for osteochondritis dissecans. Demographics including age, sex, race, body mass index (BMI) and comorbidities were collected. Perioperative factors collected were anesthesia type and operative times. Patient demographic and perioperative data were compared using Fisher's exact test and Pearson's chi-square test. Multivariate logistic regressions were used to calculate odds ratios (OR) and 95% confidence intervals (CI) of independent risk factors for postoperative admission. Holm-Bonferroni method yielded adjusted p-value thresholds for significance. RESULTS: Of the 20,819 patients undergoing ACLR with and without concomitant procedures, 3.8% of patients were admitted to the hospital in the immediate postoperative period. Following multivariate regression analysis, increased odds of admission were demonstrated with the use of regional anesthesia alone (OR = 2.77, 95%CI: 2.22-3.44; p < 0.001), increasing concurrent procedures (Table 1), and obesity classes II (OR = 1.62, 95%CI: 1.26-2.10; p < 0.001) and III (OR = 1.81, 95%CI: 1.33-2.47; p < 0.001). Subsequent subgroup analysis of the isolated ACLR procedures (N = 9,423) demonstrated a 3.3% postoperative admission rate. Multivariate regressions demonstrated increased odds of admission with regional anesthesia use only (OR = 2.62, 95%CI: 1.90-3.60; p < 0.001), obesity class II (OR = 2.22, 95%CI: 1.51-3.26; p < 0.001), and increasing minutes of operative time (OR = 1.01, 95%CI: 1.01-1.01; p < 0.001). Table 2 demonstrates increasing rates and odds of admission with increasing operative time in hours. CONCLUSION: Anterior Cruciate Ligament Reconstructions are routinely performed in an outpatient setting; nevertheless, a subset of ACLR patients is admitted postoperatively. We found an increased risk of admission with the use of regional anesthesia alone, increasing concurrent procedures and obesity classes II and III. A further understanding of patient risk factors for those undergoing ACLR allows orthopedic surgeons to better develop a preoperative plan and discuss patient expectations, which will lead to more efficient resource allocation and improved patient satisfaction.

Impact of a Resident-Guided Rounding Initiative on the Hospital Consumer Assessment of Healthcare Providers and Systems Survey Scores in Orthopaedic Surgery Inpatients.

Patient-centered medicine is becoming the main focus of many healthcare systems, and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a tool used to track patient satisfaction. In this study, we evaluate the HCAHPS scores in orthopaedic surgery inpatients before and after implementation of a resident-guided rounding protocol. Analyses of the HCAHPS surveys for 154 orthopaedic surgical inpatients at one community hospital were compared 6 months before and after implementation of a resident-guided rounding initiative. Specific questions of the HCAHPS survey were analyzed using the top box, mean, and positive scores. Implementation of the rounding initiative resulted in an increase in the top box, mean, and positive scores for all questions evaluated; however, no significance was noted in the results, with the exception of the positive score for a staff cohesiveness question (P = 0.046). Physician and hospital recommendation questions showed a 5-point increase (91st to 96th percentile) compared with 42-point increase (21st to 63rd percentile) by publicly reported national data. Implementation of the rounding initiative resulted in increases in HCAHPS scores across multiple questions and domains; however, these were not significant. These results suggest that simple interventions can help increase the overall patient satisfaction and promote future investigations.

A comparison of lumbar transverse pedicle angles between ethnic groups: a retrospective review.

BACKGROUND: Spinal surgery requires an intimate understanding of pedicle morphology to provide safe and effective outcomes. Although current research has attempted to identify morphological vertebral pedicle trends, no study has utilized computed tomography (CT) scans to compare the lumbar transverse pedicle angle (TPA) with patient demographics factors in a diverse population throughout multiple hospital centers. METHODS: Analysis of randomly selected CT scans from L1-L5 of 97 individuals who underwent imaging over a two-week period for non-back pain related complaints was conducted. Measuring 970 TPAs in total allowed for comparison of each patients' pedicle angle with important patient specific demographics including ethnicity, age, gender, height and weight. Statistical analysis utilized multiple comparisons of demographics at each level with post-hoc Bonferroni correction analysis to compare demographics at each level. RESULTS: With relation to gender, age, height or weight, no statistically significant differences were identified for TPAs at any vertebral level. However, when stratified by ethnicity, the differences in transverse pedicle angles averages (TPA -Avg) at L2 and L3 were found to be statistically significant (p < 0.05). CONCLUSION: We have identified a previously unknown and significant relationship between ethnicity and TPA at lumbar vertebral levels. These findings provide critical information that may be added to the operating surgeons' knowledge of pedicle morphology. We hope this novel information can assist in preoperative planning of pedicle screw placement and potentially help improve surgical outcomes.

Demographic Analysis of Lumbar Pedicle Diameters in a Diverse Population.

STUDY DESIGN: Retrospective chart review. PURPOSE: We sought to determine the differences in pedicle diameter (PD) in the lumbar spine between various races: 'Asian,' 'Black,' 'White,' and 'Other.' These data could aid in perioperative planning during instrumented spinal fusion. OVERVIEW OF LITERATURE: Recent literature underscores the importance of understanding diverse pedicle isthmus morphology to perform successful transpedicular procedures. These studies suggest that more detailed and reliable measurements of pedicles should be undertaken. However, none of the current literature comprehensively compares average PDs between diverse racial populations with a standardized study design. METHODS: Coronal cuts of 5,060 lumbar spine pedicles were inspected to obtain their transverse outer cortical PD as measured through the isthmus at L1-L5. Data were collected and categorized on the basis of patient-reported race. We examined average PD and PD range at each level for each race. To determine the significance, we used a mixed analysis of variance and a post hoc analysis. RESULTS: The Asian cohort consistently had a significantly smaller PD at L1-L5 than Blacks or Whites (p<0.001), as did the 'Other' group compared with Blacks (p<0.001) and Whites (p=0.032). At L1-L2, the 'Other' group showed the least variability in PD. At L3-L5, the Asian population showed the smallest range, and the Black population had the largest variability in PD except at L5. There was a significant difference in PD between the various races. CONCLUSIONS: The Asian population consistently has significantly smaller pedicles in the lumbar spine than the Black or White populations. This information could prove useful for surgical planning. We suggest using preoperative computed tomography for pedicle screw templating as a safe method for pedicle screw instrumentation with the highest pullout strength given the wide range of PD in the Black population and the variability of PD between races.